GW1--05186_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: 1_
Ve1V 1 r1 E?`\� , 6 ris,)1,1 ..I GG 1�S6t') 14.WATER ZONES
Well Contactor Na FROM TO DESCRIPTION
DESCRIPTION
'2 O ' ) � ' (OR �( ft.
ft. ft.
NC Well Contractor Certification Number .
` f�A 15.OUTER CASING(for multi-cased wells)OR LINER(If ap lieable)
I J 'V`V k k 1 1 e,\ '(1/7 r \\\1 FROM TO DIAMI TER THICKNESSy MfA�TERIAL
Company Name
•? 1 �^t rt. tv Ci Li it. (1(2,In. t 12 i-'\I C
t ray l t 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Contraction Penult#: 1 C)(3 "..1 1 b b FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. n in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: _17.SCREEN
❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn ❑MunicipaVPublic it. ft. In.
❑Geothermal(Heating/Cooling Supply) .Residential Water Supply(single)
ft. ft. [a. •
❑IndustrialCommercial 0 Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000GPD . FROM TO MATERIAL " EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. 26 ft. •8CrIal1 11 `5
❑Monitoring ❑Recovery ft. ft.
Injection Well:
-
ft. rt.❑Aquifer Recharge ❑G roundwater Remediation
❑Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Oeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES ON(color nwdae.s sow.e<xtype grabs she,.,el
O ft (D ft, 1-- c
++
4.Date Well(s)Completed: 1 3( 1 Z1/41 Well ID# b ft. q 0 ft.
5a.Well Location: :+i u ft.
470 it /
6V16.ron 13rtx,Jhe LDCuS 9drt. 260ft• .blvc /f- r1 -e'
Facility/Owner Name Facility IDS(if applicable) ft. ft.
Sq LH Limit ;- 1 I\Nunt- k i l l ft ft
P( _
Physical Address,City,and Zip n ft.
1 �iC`i Aet'1`7.2tOrt.:3 19)-7 1°11 �1 27.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22.Certification:
N W ....2__ ef:::( &,..d4_____I
3_42...q
6.Is(are)the well(s): lit Permanent or ❑Temporary Signature of Certified Well Contractor Dat
By signing thisform,I hereby certify that the well(s)s ar(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &io ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,ftI out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under i131 remarks section or on the back of thisfonn.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2,L () /
For nhuhip/e wells list all depths lfdifferent(example-3®200'and 1Q100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Stadc water level below top of sing: u f 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"/+"/ (4) Information Processing Unit,1617 MSC,Raleigh,NC 2769 9-1 6 1 7
11.Borehole diameter: 47 8 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
/� +(� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ar1 ' 120-k- 'may Y4c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:CopyD
Permit Pro 1611 MSC,Raleigh,NC 27699-1611 to CCPCUA
13a.Yield(gpm) 2-C) Method of test: 4:1''t\r-
13b.Disinfection type: 1"'4-T 4 Amount: \CNA